By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

PRIMARY PURPOSE: To provide disability case management and claim determinations based on complex medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims; coordinating investigative efforts, thoroughly reviewing contested claims, negotiating return to work with or without job accommodations, and evaluating and arranging appropriate referral of claims to outside vendors.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES 

• Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.
• Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians).
• Communicates with the claimants providers to set expectations regarding return to work.
• Determines benefits due, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
• Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
• Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
• Informs claimants of documentation required to process claims, required time frames, payment information and claims status either by phone, written correspondence and/or claims system.
• Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
• Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
• Negotiates return to work with or without job accommodations via the claimants physician and employer.
• Refers cases as appropriate to team lead and clinical case management.
• Maintains professional client relationships.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization's quality program(s).

QUALIFICATIONS

Education & Licensing
Bachelor's degree from an accredited university or college preferred.

Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience required.

Skills & Knowledge

• Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
• Working knowledge of medical terminology and duration management
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Ability to work in a team environment
• Excellent negotiation skills
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of pay for this role is $22.00 - $24.00/hr.  A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.